A 70-year-old man presents with weakness of his right arm and leg. His symptoms began yesterday and are now resolved. He also reports a 6-month history of recurrent headaches and fatigue. He is a nonsmoker. His medical history is significant for high blood pressure. His blood pressure is 167/88 mm Hg, his oxygen saturation is 93% on room air, his face is plethoric, and a right carotid bruit is heard. Other findings on physical examination are normal. Diagnostic testing results are shown in Table 9.Q5. Carotid ultrasonography shows a 30% stenotic lesion in the right carotid. The patient is hospitalized and begins antiplatelet therapy. Which of the following should you order next?

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Question 1 of 5

A 70-year-old man presents with weakness of his right arm and leg. His symptoms began yesterday and are now resolved. He also reports a 6-month history of recurrent headaches and fatigue. He is a nonsmoker. His medical history is significant for high blood pressure. His blood pressure is 167/88 mm Hg, his oxygen saturation is 93% on room air, his face is plethoric, and a right carotid bruit is heard. Other findings on physical examination are normal. Diagnostic testing results are shown in Table 9.Q5. Carotid ultrasonography shows a 30% stenotic lesion in the right carotid. The patient is hospitalized and begins antiplatelet therapy. Which of the following should you order next?

Correct Answer: A

Rationale: Polycythemia vera is suggested by hemoglobin 20.5 g/dL, hematocrit 58%, low erythropoietin, and thrombosis (TIA). JAK2 V617F mutation testing confirms it in ~90% of cases. BCR-ABL (B) screens for CML, not polycythemia. ABG (C) is unnecessary without hypoxia. Bone marrow (D) can follow later.

Question 2 of 5

Ten years ago, a previously healthy 20-year-old woman presented to her physician with a 2-month history of pruritis, drenching night sweats, unintentional weight loss, and nonproductive cough. On examination, she had 2-cm cervical lymphadenopathy. A computed tomographic scan showed a 12-cm-diameter anterior mediastinal mass. An excisional biopsy of a cervical lymph node showed nodular sclerosing Hodgkin lymphoma. After she was treated with ABVD (doxorubicin [Adriamycin], bleomycin, vinblastine, and dacarbazine) combination chemotherapy followed by involved field radiotherapy, the disease was in complete remission. Now you see her for the first time for an annual physical examination. The disease remains in complete remission. Compared to her peers, this patient is at increased risk of which of the following conditions?

Correct Answer: D

Rationale: Hodgkin lymphoma survivors post-ABVD and radiotherapy have elevated risks of breast cancer (chest radiation), coronary artery disease (radiation/cardiotoxic drugs), hypothyroidism (neck radiation), and skin cancer (radiation), making E correct.

Question 3 of 5

A 48-year-old man presents to the emergency department with a 6-week history of progressively worsening abdominal pain and night sweats. Physical examination findings were significant for palpable bilateral 2-cm axillary lymph nodes and diffuse abdominal tenderness with no rebound or guarding. Computed tomography of the abdomen and pelvis showed retroperitoneal and mesenteric lymphadenopathy. Excisional biopsy of an axillary node was positive for diffuse, large B-cell lymphoma. Positron emission tomography showed fluorodeoxyglucose-avidity in the axillary, mesenteric, and retroperitoneal lymph nodes. Results of the bone marrow examination were normal. Which of the following is the best next step?

Correct Answer: A

Rationale: Advanced-stage diffuse large B-cell lymphoma requires R-CHOP, improving survival over CHOP alone (C). Observation (B) is for indolent lymphomas. Transplant (D) is for relapse. Radiotherapy (E) suits early-stage disease, not advanced.

Question 4 of 5

Ten years later, the patient described in Questions 3 and 4 experiences recurrent hemarthroses that become refractory to standard doses of factor VIII. The most likely cause of this is

Correct Answer: B

Rationale: Factor VIII inhibitors (B) are a common complication in hemophilia A, causing resistance to replacement therapy and recurrent bleeds.

Question 5 of 5

Matching: Hemolytic anemia - Spectrin deficiency

Correct Answer: A

Rationale: Spectrin deficiency is a hallmark of hereditary spherocytosis (A), leading to membrane instability.

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